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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFADAVI~UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Eme~~ Benite:Zc~~~RNAME
1ST 0 D 1ST
2ND 0 D 2ND
3RD 0 0 3RD
~ 0 D ~
I duly swear/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is t~, d that I
as to my right to enter into the ma age state. f I";-""
21. SIGNATURE OF GROOM ~ 22. SIGN URE OF BRIDE ~' . <-- ,..
USE C RE NAME USE CURRENT NAME
23. SUBSCRIBED AND SWORN TOfAFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of t authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York te. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
10/15/2007
NY 12590
STATE ZIP
27. TYPE OF CEREMONY
o 0 RELIGIOUS 1 ~VIL
9 0 OTHER, SPECIFY
COUNTY nllkhp.~~
CITYrrOWN W~rrinop.r
~~~:~c: 1 ~RR .
~~~~~~R 1 ~ 7
1 . A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. N (~ATE)
C. CHECK ONE 0 CITY 0 TOWN./2J
~~~CIFY \AI~rrinaer~ I=~II~
D. STREET ADDRESS 7R Snllth Rp.m~p.n AVp.nllp. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? !iilI' YES 0 NO
MOQj / Dl~ / ~
B. ~~ess
VILLAGE
3. A. AGE 24
3B. DATE OF BIRTH
....
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c
wiL
"'LL
-II(
4. EMPLOYMENT
A. USUAL OCCUPATION ConstrllC'tio'1 Laborer
B. TYPE OF INDUSTRY OR BUSINESS r.h~nop. Rrirlgp. r.nn~t
5. PLACE OF BIRTH r.~li r.nh Imhi~
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Juan Bautista Benitez Lopez
B. COUNTRY OF BIRTH r.nh Imhi~
7. MOTHER
A. MAIDEN NAME Irm~ \lplp7
B. COUNTRY OF BIRTH r.nh Imhi~
8. NUMBER OF THIS MARFjIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE" '.CIVIL'ANNUl:MENT .
o
o
DEATH
n
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULlLED, PROVIDE THE FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
YEAR
w
U)
Z
W
o
::i
~
{ SEAL }
~
NAME (PRINT)
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
f:,eVl t ~ 'l..
SIGNATURE~
bOH-98 (0312006)
.
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
--1
11. A. FULL NAME FIRST Palll~I~?Edrp~ C€lr1~~1e'~t'SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Cardenas Benitez
c. s~S~I~M~~~t~~~~~s~ardenas
D. SOCIAL SECURITY NUMBER 149-02-3308
12. RESIDENCE A. NIB. (Ininn
,STATE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY Fli7~hp.th
D. STREET ADDRESS 627 Grier Avenue 2nd FI. ZIP 07207
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE 34 3B. DATE OF BIRTH 03 A? ,,{q7~
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION r.11~tnmpr Spvir.p Agpnt
B. TYPE OF INDUSTRY OR BUSINESS Continental Airlines
15. PLACE OF BIRTH r.~I~_ Columbia
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
,A. NAME SPOlll1do Gilhertn G~rrlpn~~ Aronti
B. COUNTRY OF BIRTHr.nlllmbia
17. MOTHER
A. MAIDEN NAME M~ria .Jn~p.f~ Bp.nitp.z L npez
B. COUNTRY OF BIRTHCnlumbia
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
B. HOW DID LAST MARRIAGE END?
(3) o DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,'- YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULlLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY/COUNTY, STATEfCOUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
lare that no legal impediment exists
t::/____ c.. 5.
1 0/15/2007
TIME
MONTH
MONTH
YEAR
YEAR
09:05AM
PM
10
16
2007
12
14 2007
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~ \;( { C~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~ILLA~
SPECIFY WtJdlfJ, r...6~ ~~
NAME (PRINT)
SIGNATURE~